A parent brings a 4-month-old infant to the clinic.
The infant has had a runny nose, a slight fever, and a cough for the last two days.
Which of the following findings should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/min.
Bilateral bronchial breath sounds.
Flaring of the nares.
The Correct Answer is D
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The antibiotic cefdinir is used to treat many different types of infections caused by bacteria. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.
Choice B rationale
Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. The emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.
Choice C rationale
Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While these foods are part of a balanced diet, they do not have specific benefits for a person taking cefdinir.
Choice D rationale
Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.
Correct Answer is A
Explanation
Choice A rationale
In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.
Choice B rationale
While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice C rationale
The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice D rationale
The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
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